With looming threats of a United States Department of Justice ("USDOJ") investigation of Coalinga State Hospital ("CSH"), allegations of a coup d'etat by the Hospital Police, a possible outside investigation of criminal medical malpractice, hospital staff leaving in droves, an imminent sit-down strike by patients, and personal liability from lawsuits, Acting Executive Director of CSH, Ben McLain, resigned abruptly on August 3, 2007. Mr. McLain, who had been on vacation for the previous two weeks, simply did not return - resigning instead.

McLain's resignation followed that of his predecessor by just a few months. W. T. "Tom" Voss, was the original Executive Director who opened the hospital in 2005. Tom Voss spent approximately one and a half years after its opening attempting to get the Department of Mental Health's "White Elephant" at Coalinga up and running. He was plagued by not only trying to lure staff to the desolate and toxic Coalinga area, but also by his wife contacting Valley Fever in the Coalinga area and nearly dying. Tom Voss fled this post at CSH in April 2007.

Although it is merely speculation as to why administrative personnel are abandoning CSH, there is no shortage of such speculation based on recent events:

Medical care is generally lacking and slow in coming. One patient, whose name will be withheld pursuant to the Health Information Practices Act ("HIPA"), has been suffering from skin cancer since his arrival at CSH. He has lost his one ear, and has hunks of cancerous skin hanging from his face. In nine months, the hospital has done little to nothing to address this serious medical problem. According to this patient, he has consulted specialists, who have informed him and the hospital that his cancer has been neglected for so long that it will now take drastic measures to save his life. Any observer can look at him and see he is not exaggerating his condition. Also, according to this patient, the USDOJ is taking steps to have him removed from the custody of CSH as they consider his life to be in danger at that facility.

There are many other medical abuse stories not detailed herein. Patients have filed claims with numerous outside agencies, and watchdog groups, including the Fresno County Grand Jury, alleging criminal medical malpractice and dependant adult abuse. An actual investigation will eventually occur. The conditions being complained of are similar to those that resulted in the CDCR medical system being placed in Federal receivership. It's only a matter of time.

Several administrators and staff at CSH are defendants in a class action lawsuit, Hydrick, et al. v. Davis, et al., USDC Case Number CV 98-7167 TJH (RNBx). This lawsuit was originally filed by patients housed at Atascadero State Hospital ("ASH"), but who are now housed at CSH. The State has lost this lawsuit at every stage of the proceedings. The latest loss for the State being at the United States Court of Appeals for the Ninth Circuit. That decision is published in the Federal Reporter at 449 F.3d 978. In spite of their losses, the State continues to appeal while accumulating a huge financial liability at taxpayer expense. Apparently, the State would rather appeal than attempt to fix the underlying problems which cause the liability.

Patients have claimed the named defendants in the Hydrick lawsuit should not be allowed to make policy at CSH, and should be recused from policy-making decisions.

Since CSH first opened its doors, the facility has been plagued with a lack of staff. This mainly due to the remote location of the Hospital, and the fact that this particular remote location is an extremely undesirable area in which to live. The recruiting package simply lies to potential recruits. Then as new employees, many soon leave after seeing CSH and its problems for themselves. Many staff have left for better pay with the Department of Corrections and Rehabilitation ("CDCR"). Even though the DMH has since increased pay rates, the staff hemorrhage continues. Many are openly commenting on their way out that they are leaving because of poor supervision and administration.

Due to the lack of necessary staff to properly operate the Coalinga facility, the patients routinely complain about the lack of sanitation and general cleanliness. The facility has been open just shy of two years at this time, and already has a mold problem in the showers and bathrooms. The corridors and housing units are filthy. One cannot blame the janitorial staff per se, as there just are not enough of them. As individual janitors, they try to do the best they can.

Up to fifty-three patients now are forced to share very small bathrooms which are filthy due to inadequate cleaning. They are often out of toilet paper, soap, and paper towels. There is often fecal matter on the toilet seats and urine on the floors. There is a lack of maintenance staff to repair clogged toilets, resulting in effluent overflowing onto the flour, sometimes for days, before repairs are made. We all know that this does happen in bathrooms. The problem is CSH is a hospital, and hospitals are expected to be kept in a sanitary condition. Yet at CSH, there is no staff available to clean-up such a mess when it does happen.

CSH is located down wind from the second largest feedlot in the world, Harris Ranch, so flies and other insects are abundant in the area. Thus, patients often complain about excessive numbers of flies in the dining areas and in their food. Although "Air Curtains" are installed to keep flies from entering from the outside when the meals are delivered three times daily, they are not in operation because CSH claims they do not have any electricians to run power to these units. However, CSH does appear to have enough electricians to get new housing units up and running, and increase the patient population.

The real problem continues to lie with the Hospital's administrators who keep increasing the patient population without increasing the resources and ancillary staff to adequately care for these patients. The Legislature didn't help matters when it passed legislation exempting CSH from hospital licensing requirements, and thus effectively exempting the facility from any oversight whatsoever.

In 2005, when the DMH was unable to staff the new facility, the California Legislature enacted legislation relieving the DMH of licensing requirements by authorizing, "the voluntary suspension on health facility beds at Coalinga State Hospital for a period of up to 6 years...... This effectively allowed the present CSH policy of staffing the hospital units not by professionals, but rather by Department of Police Services ("DPS") police officers.

Following a series of assaults on at least three Black patients, that black patient population has alleged racism within the DPS. DPS Officers often override medical orders stating, "We run this hospital." The patient population, through its representatives, has complained that CSH is not a hospital, but rather, a prison. The patients have also alleged that the hospital police have taken over the facility; that the clinical administration has lost control of the hospital.

A large group of patients who are just plain fed up with the abuse at CSH sent the Hospital Administration a list of grievances on August 2, 2007, demanding that the Hospital come into compliance with current State and Federal laws, rules and regulations. This packet consisted of more than fifty pages, and will not be detailed herein due to the large Volume of information it contained. Let it suffice to say that this list contained detailed information on many of the abuses presented in this article along with several other complaint topics. All of which involve the institution's violation of some statute, rule, regulation, policy or practice, or the State and/or Federal Constitution. The patient sit-down strike materialized on Monday morning, August 6, 2007.

When patient representatives meet with CSH supervisory or administrative personnel, and complain about specific problems, they are often proffered the excuse that, "I was ordered to do that." This sounds like the old "Nuremberg Defense," which was used by Nazi war criminals who attempted to escape culpability for their crimes because they were ordered to do so by their superiors. This defense did not work for the Nazis, has not worked throughout history, and most likely will not allow the employees at CSH to escape liability for any action that is either unconstitutional, in violation of statute, or criminally illegal.

Thus, although there may be many other additional reasons, speculation has it that the CSH administration and staff are fleeing a sinking ship, much like many Nazis fled to South America following World War Two.

Tom Watson (8 August 2007)

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